Provider Demographics
NPI:1275912164
Name:BRONICO, JACKIE VALESCA RODRIGUEZ (MD, MSC)
Entity Type:Individual
Prefix:DR
First Name:JACKIE
Middle Name:VALESCA RODRIGUEZ
Last Name:BRONICO
Suffix:
Gender:F
Credentials:MD, MSC
Other - Prefix:DR
Other - First Name:JACKIE
Other - Middle Name:VALESCA
Other - Last Name:RODRIGUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:34 E NEWTON ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-1944
Mailing Address - Country:US
Mailing Address - Phone:617-286-4565
Mailing Address - Fax:
Practice Address - Street 1:1035 CAMBRIDGE ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02141-1057
Practice Address - Country:US
Practice Address - Phone:617-286-4565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-25
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GATM109207R00000X
390200000X
NY307533-01207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program